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GEDMINAS INSURANCE and FINANCIAL SERVICES
This is not an instant quote website; our prices are too low to list online. Please fill out the quote form to obtain a Life insurance quote, and an insurance specialist will contact you shortly. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
 
* Required Information
Life Insurance Fact Finding Questions
In regards to your insurance, what is most important to you? Service 
  Cost/Premium 
  Proper Coverage 
Approximately, when was the last time you did a review with your agent? Within the year 
  Over 2 years ago 
  Over 5 years ago 
  Never 
Please rate the following in the order that you feel are most important for
you to protect (1 being most important)?		 Income:
  Auto:
  Savings:
  Home:
  Other:
To receive greater discounts on your insurance, would you be interested in
combining your home and auto and life insurance to save up to 45%?		 Yes      No 
   
   
Contact Information
Contact Name
Address
City
State
Zip Code
Primary Phone to Reach You:
Alternate Phone # to Reach You:
* Email
Fax
Contact Me During:
   
   
First Proposed Insured's Information
First Name
Last Name
Age
Gender Male     Female 
Height
Weight
Last Time Tobacco was Used
Amount of Coverage
Date of Birth
Has proposed insured ever been diagnosed or been treated for: Diabetes, Cancer, Heart Disease, Alcoholism or Drug Abuse Yes     No 
Has proposed insured ever been diagnosed or treated for high blood pressure? Yes     No 
What Type of Life Insurance are you interested in
How Long is Coverage Needed?
Does The Proposed Insured Currently Have Life Insurance? Yes     No 
                If Yes, Premium $
   
   
Second Proposed Insured's Information
First Name
Last Name
Age
Gender Male     Female 
Height
Weight
Last Time Tobacco was Used
Amount of Coverage
Date of Birth
Has proposed insured ever been diagnosed or been treated for: Diabetes, Cancer, Heart Disease, Alcoholism or Drug Abuse Yes     No 
Has proposed insured ever been diagnosed or treated for high blood pressure? Yes     No 
What Type of Life Insurance are you interested in
How Long is Coverage Needed?
Does The Proposed Insured Currently Have Life Insurance? Yes     No 
                If Yes, Premium $
Do you have any Questions or Suggestions?
   

Gedminas Insurance Services • CA LIC: 0E66327
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